Provider Demographics
NPI:1083648703
Name:MALL, RONALD MARTIN (DO)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:MARTIN
Last Name:MALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13020 PARK BLVD
Mailing Address - Street 2:OAKHURST MEDICAL CLINIC
Mailing Address - City:SEMIONLE
Mailing Address - State:FL
Mailing Address - Zip Code:33776
Mailing Address - Country:US
Mailing Address - Phone:727-393-3404
Mailing Address - Fax:727-394-1804
Practice Address - Street 1:3800 EAST BAY DRIVE
Practice Address - Street 2:EAST BAY MEDICAL CENTER
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33771
Practice Address - Country:US
Practice Address - Phone:727-539-0505
Practice Address - Fax:727-394-1804
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS0003675208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
2337655OtherAETNA
267070OtherAVMED
2337655OtherAETNA
82081WMedicare ID - Type Unspecified